HomeMy WebLinkAbout0491 Qe~laration ot Dort~i~ile and citise~ship 212'7Q2
f~ THE STATE AND COUh1TY TAX ASSE~SOR,
Si. lUC1E COUNTY, f;ORIDA
Th~s ~s my declarat~on of ~om~ule and Cit~zensh~p in the Stare of Florida that I am filiRg this day ~n accordance a~d
~n c~nformity w~th Chaprer 222, Section 222.17, Flor~da Statutes.
I was formerly a legal ~esident of ~
(C~ty) (Stat~)
a~d I resided at -7 ~ i~~ - However I have changed my domiC~le
~ (Street and Numoer)
to and am and have been a bona fide resident of the Stats of Florida since l b-~ _ day of
, 19_ 7 and 1 reside at ~
(Street and Number)
FORT PtERCE, SAINT lUC1E COUNTY, FIORIDA
~nd this statement is !o be taken as my declaration of citizenship, actual legal residence and domicile in ihe State of Flo~ida.
(Insert here any pertinen: facts, suth as sale of property or business, or relinquishment ;,f employment
at former domicile, removal of family to rew domicile, purchase of home, etc.)
212'702 {
fi~EO ~+e~ ~ecoa~Ep
ST R06EP.CP0ITRAS~ ~
CtERK CI~CUIT COURTP~
~ _ RECORD YERIf1E0
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• ~`'l`~' .l~ 11 2 34 PM'T I
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~ I FURTHER CERTIFY that 1 will comply with all other requirements of a legal resident of this State.
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1 FURTHER CERTIFY that I have no intention to ~eturn to my former domi~ile, and I intend to remain in FORT
PI[RCE, SAINT LUCiE COUNTY, FLORIDA, permanently_
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~~~x 3 ~ 7 , - - ~.c~,~~ 33 Y~''1
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~ Swom to and subscnbed befere me this _ _?~r day of _ _ _ _ 19___ .
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~ ROGER POITRAS : ~ r - - -
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~ K CIRCUIT CDURT - • ' • = Notary Public
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~ By ~ • 0.~._ • My ~ommission expires
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~ (To be executed in duplicate and original fil~d vrit~.t`Itrk Grcuit Court, snd dupiicate with Tax Assessor.)
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$ L'-' 1y4 491
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